Optimal Z-Score Use in Surgical Decision-Making in Pulmonary Atresia With Intact Ventricular Septum

Awori, Mark Nelson; Mehta, Nikita; Mitema, Frederick O.; Kebba, Naomi

doi:10.1177/2150135117701407

Cited by 23 publications

(13 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Fetal studies have suggested that a hypoplastic TV ( z -score <–3) at initial assessment [6, 11] as well as a lower rate of TV growth through gestation are associated with a single-ventricle circulation [6]. Postnatally, a TV z -score of <–5 has been used as a cut-off for determining single-ventricle circulation [2], but there is variability in cut-off values used in practice [12].…”

Section: Introductionmentioning

confidence: 99%

Fetal Cardiac Intervention for Pulmonary Atresia with Intact Ventricular Septum: International Fetal Cardiac Intervention Registry

et al. 2020

View full text Add to dashboard Cite

Introduction: Invasive fetal cardiac intervention (FCI) for pulmonary atresia with intact ventricular septum (PAIVS) and critical pulmonary stenosis (PS) has been performed with small single-institution series reporting technical and physiological success. We present the first multicenter experience. Objectives: Describe fetal and maternal characteristics of those being evaluated for FCI, including pregnancy/neonatal outcome data using the International Fetal Cardiac Intervention Registry (IFCIR). Methods: We queried the IFCIR for PAIVS/PS cases evaluated from January 2001 to April 2018 and reviewed maternal/fetal characteristics, procedural details, pregnancy and neonatal outcomes. Data were analyzed using standard descriptive statistics. Results: Of the 84 maternal/fetal dyads in the registry, 58 underwent pulmonary valvuloplasty at a median gestational age of 26.1 (21.9–31.0) weeks. Characteristics of fetuses undergoing FCI varied in terms of tricuspid valve (TV) size, TV regurgitation, and pulmonary valve patency. There were fetal complications in 55% of cases, including 7 deaths and 2 delayed fetal losses. Among those who underwent successful FCI, the absolute measurement of the TV increased by 0.32 (±0.17) mm/week from intervention to birth. Among 60 liveborn with known outcome, there was a higher percentage having a biventricular circulation following successful FCI (87 vs. 43%). Conclusions: Our data suggest a possible benefit to fetal therapy for PAIVS/PS, though rates of technically unsuccessful procedures and procedure-related complications, including fetal loss were substantial. FCI criteria are extremely variable, making direct comparison to nonintervention patients challenging and potentially biased. More uniform FCI criteria for fetuses with PAIVS/PS are needed to avoid unnecessary procedures, expose only fetuses most likely to sustain a benefit, and to enable comparisons to be made with nonintervention patients.

show abstract

Section: Introductionmentioning

confidence: 99%

Fetal Cardiac Intervention for Pulmonary Atresia with Intact Ventricular Septum: International Fetal Cardiac Intervention Registry

et al. 2020

View full text Add to dashboard Cite

show abstract

“…TV annulus z‐score will be −1.37 in the same patient according to the Pettersen z‐score data set 15 . Therefore, Awori et al 30 made an optimization study using the literature about patients with PA/IVS and they recommended the use of the Peterson et al 15 data set to determine z‐score in patients with PA/IVS. We calculated z‐scores using data of Peterson et al 15 as similar to two major cohort studies and based on the Awori et al recommendation 13,14,30 …”

Section: Discussionmentioning

confidence: 99%

Transcatheter radiofrequency pulmonary valve perforation in newborns with pulmonary atresia/intact ventricular septum: Echocardiographic predictors of biventricular circulation

et al. 2020

View full text Add to dashboard Cite

Objective We report a single‐institute experience of neonatal transvenous radiofrequency pulmonary valve perforation for pulmonary atresia/intact ventricular septum, with echocardiographic predictors of biventricular circulation. Methods Data were reviewed retrospectively for all neonates who underwent primary transvenous pulmonary valve perforation for pulmonary atresia/intact ventricular septum between January 2008 and November 2018 at our institution. We compared patients who need systemic‐to‐pulmonary shunt or ductal stenting with patients who did not need. Results During the study period, 31 patients with pulmonary atresia/intact ventricular septum underwent successful radiofrequency pulmonary valve perforation and balloon dilation of the pulmonary valve. There was no procedure‐related mortality. Sixteen patients (52%) needed systemic‐to‐pulmonary shunt or ductal stenting after initial procedure. Among the survivors (follow‐up time of 1 to 11.5 years), 15 patients had a biventricular circulation and 6 patients had 1 and 1⁄2 ventricular circulation. Two patients are awaiting for Fontan operation. Both the TV/MV annulus ratio (>0.85) and tricuspid valve z‐score (>−1) were found to be a good predictor of a biventricular outcome in our cohort. Conclusions Percutaneous radiofrequency pulmonary valve perforation and balloon valvotomy is an effective and safe primary treatment strategy for neonates with pulmonary atresia/intact ventricular septum. Ductal stenting or systemic‐to‐pulmonary shunt may be required in the majority of patients who had smaller right heart components. Preselection of patients according to tricuspid valve z‐score and TV/MV annulus ratio allows predicting biventricular circulation.

show abstract

“…Awori et al (2011) noted that the use of poorly calibrated tools and protocols to measure cardiac structure size could introduce a systematic error in measurement. This may result in an incorrect assessment of cardiac structure size which could result in the execution of inappropriate surgery (Awori et al, 2017). Awori et al (2011) proposed an optimal method to measure cardiac structure size and the NPAI calculated Girod et al (1985) 1985 for typical patients of various ages, using this technique is shown in Table 3.…”

Section: Discussionmentioning

confidence: 99%

“…There is evidence that the best long-term outcomes are associated with certain perioperative pulmonary arterial physiological parameters (Pundi et al, 2015) and that branch pulmonary artery (BPA) size contributes to the presence or absence of these parameters (Itatani et al, 2011). Prior work done in relation to the accurate measurement of the size of cardiac structures has shown that the use of poor protocols lead to the introduction of systematic errors in measurement and may contribute to poor surgical decision making (Awori et al, 2017). The objective of the current study was to determine if the ambiguity regarding the relationship between the outcome of Fontan surgery and the size of branch pulmonary artery may have been introduced by a systematic error of pulmonary artery size measurement.…”

Section: Introductionmentioning

confidence: 99%

Possible impairment of surgical decision making and confounded outcome in Fontan surgery by Nakata Index

Awori¹,

Mehta²,

Kebba³

et al. 2020

Afr. Ann. Thorac. Cardiovasc. Surg.

View full text Add to dashboard Cite

Since cardiac structuring dimensions inform surgical decisions making, Z-score systematic error impairs surgical decision making and confounds outcome measurement, hence a similar error may affect the Nakata index. In this study, PubMed was searched using the terms: "pulmonary," "artery," "size," "Nakata," "Fontan," and "outcome". Studies that did not describe the outcome of the Fontan procedure and the size of the branch pulmonary arteries were excluded. Outcome measures of interest, in relation to BPA size, included: Operative mortality, Fontan "take-down", length of ICU stay, pleural effusions and functional capacity. The results revealed that of 116 papers retrieved, 9 were included representing 1,042 patients who underwent the Fontan procedure. Six out of 9 papers representing 645 (61.9%) patients reported that BPA size had no relationship with the outcome of the Fontan procedure; while 2 out of 9 papers representing 366 (35.1%) patients found that BPA size did affect the outcome. One paper representing 31 (3%) patients was unable to find any relationship. All the papers that concluded that there was no relationship labelled normal sized BPAs as small because of a systematic error introduced by the Nakata index. Papers that found a relationship did not use the Nakata index. Thus, Nakata index systematic error may impair surgical decision making and confound outcome measurement in Fontan surgery. In addition, continued use of the Fontan index may have similar implications for other congenital heart lesions.

show abstract

Optimal Z-Score Use in Surgical Decision-Making in Pulmonary Atresia With Intact Ventricular Septum

Abstract: The use of varied tricuspid valve annuli z-score data sets may have contributed to gross variations in reported "cutoffs" for successful biventricular repair. This could lead to inappropriate surgical pathway allocation.

Cited by 23 publications

References 26 publications

Fetal Cardiac Intervention for Pulmonary Atresia with Intact Ventricular Septum: International Fetal Cardiac Intervention Registry

Fetal Cardiac Intervention for Pulmonary Atresia with Intact Ventricular Septum: International Fetal Cardiac Intervention Registry

Transcatheter radiofrequency pulmonary valve perforation in newborns with pulmonary atresia/intact ventricular septum: Echocardiographic predictors of biventricular circulation

Possible impairment of surgical decision making and confounded outcome in Fontan surgery by Nakata Index

Contact Info

Product

Resources

About